Provider Demographics
NPI:1073500815
Name:CLARK, STEPHEN JOSEPH (MSW)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JOSEPH
Last Name:CLARK
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17414 BOTHELL WAY SE
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-6334
Mailing Address - Country:US
Mailing Address - Phone:425-775-5955
Mailing Address - Fax:425-481-8367
Practice Address - Street 1:17414 BOTHELL WAY SE
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-6334
Practice Address - Country:US
Practice Address - Phone:425-775-5955
Practice Address - Fax:425-481-8367
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000062231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAR79252Medicare UPIN